Seth M. Holmes

An Ethnographic Study of the Social Context of Migrant Health in the United States

Background Migrant workers in the United States have extremely poor health. This paper aims to identify ways in which the social context of migrant farm workers affects their health and health care. Methods and Findings This qualitative study employs participant observation and interviews on farms and in clinics throughout 15 months of migration with a group of indigenous Triqui Mexicans in the western US and Mexico. Study participants include more than 130 farm workers and 30 clinicians. Data are analyzed utilizing grounded theory, accompanied by theories of structural violence, symbolic violence, and the clinical gaze. The study reveals that farm working and housing conditions are organized according to ethnicity and citizenship. This hierarchy determines health disparities, with undocumented indigenous Mexicans having the worst health. Yet, each group is understood to deserve its place in the hierarchy, migrant farm workers often being blamed for their own sicknesses. Conclusions Structural racism and anti-immigrant practices determine the poor working conditions, living conditions, and health of migrant workers. Subtle racism serves to reduce awareness of this social context for all involved, including clinicians. The paper concludes with strategies toward improving migrant health in four areas: health disparities research, clinical interactions with migrant laborers, medical education, and policy making.

Immigration as a Social Determinant of Health

Although immigration and immigrant populations have become increasingly important foci in public health research and practice, a social determinants of health approach has seldom been applied in this area. Global patterns of morbidity and mortality follow inequities rooted in societal, political, and economic conditions produced and reproduced by social structures, policies, and institutions. The lack of dialogue between these two profoundly related phenomena-social determinants of health and immigration-has resulted in missed opportunities for public health research, practice, and policy work. In this article, we discuss primary frameworks used in recent public health literature on the health of immigrant populations, note gaps in this literature, and argue for a broader examination of immigration as both socially determined and a social determinant of health. We discuss priorities for future research and policy to understand more fully and respond appropriately to the health of the populations affected by this global phenomenon.

The clinical gaze in the practice of migrant health: Mexican migrants in the United States

This paper utilizes eighteen months of ethnographic and interview research undertaken in 2003 and 2004 as well as follow-up fieldwork from 2005 to 2007 to explore the sociocultural factors affecting the interactions and barriers between U.S. biomedical professionals and their unauthorized Mexican migrant patients. The participants include unauthorized indigenous Triqui migrants along a transnational circuit from the mountains of Oaxaca, Mexico, to central California, to northwest Washington State and the physicians and nurses staffing the clinics serving Triqui people in these locations. The data show that social and economic structures in health care and subtle cultural factors in biomedicine keep medical professionals from seeing the social determinants of suffering of their unauthorized migrant patients. These barriers lead clinicians inadvertently to blame their patients--specifically their biology or behavior--for their suffering. This paper challenges the focus of mainstream cultural competency training by showing that it is not the culture of the patient, but rather the structure and culture of biomedicine that form the primary barriers to effective multicultural health care.

Screening the soul: Communication regarding spiritual concerns among primary care physicians and seriously ill patients approaching the end of life

The purpose of this study was to explore the spiritual concerns of seriously ill patients and the spiritual-care practices of primary care physicians (PCPs). Questionnaires were administered to outpatients (n = 65, 90 percent response rate) with end-stage illness and to PCPs (n = 67, 87 percent response rate) in a diverse general medicine practice. Most patients (62 percent) and PCPs (68 percent) considered it important that physicians attend to patients’ spiritual concerns. However, few patients reported receiving such care, and most (62 percent) did not think it was the PCP’s job to talk about spiritual concerns. Although both seriously ill outpatients and PCPs assert the importance of spiritual concerns, PCPs often do not provide spiritual care. Appropriate provision of spiritual care within a diverse population of seriously ill outpatients is complex, necessitating appropriate and attentive screening.

Structural Vulnerability and Hierarchies of Ethnicity and Citizenship on the Farm

Every year, the United States employs nearly two million seasonal farm laborers, approximately half of whom are migrants (Rothenberg 1998). This article utilizes one year of participant observation on a berry farm in Washington State to analyze hierarchies of ethnicity and citizenship, structural vulnerability, and health disparities in agriculture in the United States. The farm labor structure is organized along a segregated continuum from US citizen Anglo-American to US citizen Latino, undocumented mestizo Mexican to undocumented indigenous Mexican. The ethnography shows how this structure symbolically reinforces conflations of race with perceptions of civilized and modern subjects. These hierarchies produce what is now understood in medical anthropology as structural vulnerability among those with poor living and housing conditions, producing social disparities in health. The ethnographic data argue against the common presumption that social hierarchies are willed by powerful individuals by showing the structural production of these social inequalities and their concomitant health disparities.

Structural Vulnerability: Operationalizing the Concept to Address Health Disparities in Clinical Care.

The authors propose reinvigorating and extending the traditional social history beyond its narrow range of risk behaviors to enable clinicians to address negative health outcomes imposed by social determinants of health. In this Perspective, they outline a novel, practical medical vulnerability assessment questionnaire that operationalizes for clinical practice the social science concept of “structural vulnerability.” A structural vulnerability assessment tool designed to highlight the pathways through which specific local hierarchies and broader sets of power relationships exacerbate individual patients’ health problems is presented to help clinicians identify patients likely to benefit from additional multidisciplinary health and social services. To illustrate how the tool could be implemented in time- and resource-limited settings (e.g., emergency department), the authors contrast two cases of structurally vulnerable patients with differing outcomes. Operationalizing structural vulnerability in clinical practice and introducing it in medical education can help health care practitioners think more clearly, critically, and practically about the ways social structures make people sick. Use of the assessment tool could promote “structural competency,” a potential new medical education priority, to improve understanding of how social conditions and practical logistics undermine the capacities of patients to access health care, adhere to treatment, and modify lifestyles successfully. Adoption of a structural vulnerability framework in health care could also justify the mobilization of resources inside and outside clinical settings to improve a patient’s immediate access to care and long-term health outcomes. Ultimately, the concept may orient health care providers toward policy leadership to reduce health disparities and foster health equity.

Ethnography of health for social change: impact on public perception and policy.

Social Science & Medicine 99 (2013) 116e118 Contents lists available at ScienceDirect Social Science & Medicine journal homepage: www.elsevier.com/locate/socscimed Introduction Ethnography of Health for Social Change: Impact on public perception and policy Introduction This special issue addresses a core problem of social science: the relationship of research to public perception and policy. It focuses on the potential impact of ethnographic research on the way its au- diences see health problems, conduct their professional and per- sonal lives, and become politically active. How can ethnography foster public engagement in health issues? Ethnography has an established role in health research. It eluci- dates the cultural logics driving health related behavior, and the un- examined assumptions that frame problems of relevance to health. It places these findings in historical, economic and political context in ways that quantitative research alone does not. And given the widespread use of narrative in mass media’s shaping of public opinion in the U.S., ethnographic narratives promise to make a distinct contribution to public perceptions and policy. Medical an- thropology and sociology have long been employing ethnographic methods to answer specific health and medicine-related questions. They have had a demonstrable impact on professional and organi- zational practices as well as on our theoretical understandings of health and medicine. But what broader effects might ethnographic work, ranging from theoretical to applied, have on public discourse and policy agendas? This is a question for cultural anthropology and qualitative soci- ologydfields that have called for self-examination regarding the public relevance of their work (Burawoy, 2009; Gans, 2010). It is also a question for qualitative public health and policy researchers, whose methodologies may be less established within their larger disciplines. In the U.S., national meetings of the American Anthro- pological Association, and academic publishers such as the editors of the journal Ethnography and of the University of California Press book series on Public Anthropology, strive to bring ethnography to bear on issues of public importance. Leaders in a movement within academia to promote public ethnography have defined it as “The type of research and writing that directly engages with the critical social issues of our time.Authors of such works passionately inscribe, translate, and perform their research in order to.emo- tionally engage, educate, and move the public to action.” (Tedlock, 2007) Yet there is little consensus on how to achieve this goal. Articles in this special issue describe ethnographic research of relevance to health and consider the actual or potential impact of their findings on public debate and policy. In order to demonstrate cross cutting core issues, as well as the specificity and diversity of the ways that ethnographic research reaches larger publics in particular contexts, we deliberately include ethnographers working in geographically and thematically diverse settings. 0277-9536/

Is it worth risking your life? Ethnography, risk and death on the U.S.-Mexico border.

e see front matter O 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.socscimed.2013.11.001 Contributors to this issue cluster around three cross cutting topics in which ethnography has historically played a prominent role: 1) critical perspectives on global health; 2) marginalizing pro- cesses of poverty, stigma and violence; and 3) community based participation and advocacy. First, global health initiatives have required the fine grained and interpretive perspective offered by ethnographers, which has led to indispensable insights among global health practitioners and agencies about the ways that concepts and interventions do, or do not, translate across borders, languages and cultural groups (Janes, 2010; Kleinman, 2010; Nichter, 2008). In fact, ethnographers are often able to explain counterintuitive outcomes when health in- terventions are transported from one locale to another. Second, ethnographers have historically had unique access to marginalized groups, and attended to their on-the-ground lived ex- periences, illuminating both the local mechanisms by which larger policies or institutions negatively impact health, and the ways that marginalized groups attempt to adapt to and resist unfavorable pol- icies and institutions (Hammersley & Atkinson, 2007; Kleinman, Das, & Lock, 1997). Third, when these groups or health organiza- tions attempt to advocate for themselves against the larger struc- tural forces that entrench health and social inequalities, ethnographers are often those who document this advocacy and its symbolic and material sources. The ethnographic stance of rep- resenting alternative world views lends itself to envisioning alter- native politics and institutions. It also lends itself to participatory research in which research subjects shape the questions and prod- ucts of health research itself (Israel, 2005; Minkler & Wallerstein, The ethnographic record is rich with research that illuminates health inequalities and calls for social change as health intervention. Ethnographers are often called upon to assess the effects of profes- sional and institutional practices on health outcomes. And a growing number of ethnographers are “studying up; ” analyzing the cultural frames and social practices of large institutions, professionals, scien- tists, marketers, journalists and policy-makers themselves. Yet the ways that their diverse ethnographies inform publics and policy makers have seldom been examined in a systematic way. This special issue takes up the question of how ethnographic research can uniquely contribute to public perception and policy surrounding health issues. It poses this question to academic, theo- retical ethnographers who pursue topics of public interest. To that end, this issue assembles the work of ethnographers who strive to illuminate the social mechanisms of health disparities, as well as an anthropologist-cum-magazine publisher, an online editor, a policy- maker-cum-visual ethnographer, and a local and national health official who comment on these ethnographic perspectives from

En-case-ing the Patient: Disciplining Uncertainty in Medical Student Patient Presentations

Every year, several hundred people die attempting to cross the border from Mexico into the United States, most often from dehydration and heat stroke though snake bites and violent assaults are also common. This article utilizes participant observation fieldwork in the borderlands of the US and Mexico to explore the experience of structural vulnerability and bodily health risk along the desert trek into the US. Between 2003 and 2005, the ethnographer recorded interviews and conversations with undocumented immigrants crossing the border, border patrol agents, border activists, borderland residents, and armed civilian vigilantes. In addition, he took part in a border crossing beginning in the Mexican state of Oaxaca and ending in a border patrol jail in Arizona after he and his undocumented Mexican research subjects were apprehended trekking through the borderlands. Field notes and interview transcriptions provide thick ethnographic detail demonstrating the ways in which social, ethnic, and citizenship differences as well as border policies force certain categories of people to put their bodies, health, and lives at risk in order for them and their families to survive. Yet, metaphors of individual choice deflect responsibility from global economic policy and US border policy, subtly blaming migrants for the danger - and sometimes death - they experience. The article concludes with policy changes to make US-Mexico labor migration less deadly.

Locating global health in social medicine

The problem-oriented medical record is the widespread, standardized format for presenting and recording information about patients, which is taught to future physicians early in their medical training. Based on our participant observation of medical training, we analyze the ways in which the patient presentation operates in medical training as a disciplinary technology that manages uncertainty in the clinical decision-making process. We uncover various mechanisms at work including the construction of a coherent narrative structure in which chaotic experiences are re-organized and re-interpreted to fit neatly in a linear plot with a predictable ending, the atomization of the patient as a whole into separable “problems,” the attempt to solve these “problems” as though they are independent of one another, and the mystification of translations in scale, which give rise to much of the uncertainty in medicine. Operating at the boundary of the chaotic and often ungraspable world of the suffering experience of the patient and the highly structured realm of the medical record, a patient presentation is one medium through which both a disciplined record of experience and disciplined medical practitioners are produced. This process functions to transform the human subject patient into a recognizable, generic clinical case, and the medical student into an identifiable, professional future physician.